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Reactive arthritis is a member of the spondyloarthropathy family, the family of conditions which includes AS. Giardia is an intestinal parasite which is common in certain areas of the world. It is usually spread through contact with contaminated water. Giardia-induced reactive arthritis is a treatable form of spondyloarthropathy- eradication of the parasite results in remission of the associated arthritis. Giardia-induced reactive arthritis is probably underdiagnosed, since it is not often considered. Metronidazole (Flagyl ) is often used as the treatment for giardia, and in many cases only a short course is needed . Metronidazole is generally viewed as a safe medication (more on metronidazole in the pharmacy forum).

My son, now 17, developed joint pain after travel/exposure to an "uncertain" water source at the age of eight. At his worst (age 12-14), he was unable to stand, let alone walk, due to pain in the hip/groin area of both legs. The longest flare lasted five weeks, resulted in hospitalization and required steroid treatment to resolve. He suffered two more years of these strong flares, occurring every few months and requiring steroid treatment for resolution. Through reading on the internet and through reading in the medical school library, I came to be aware of the existence of the condition of parasite-induced reactive arthritis. Based on the history of travel and exposure to possibly contaminated water just prior to the start of pain, we asked the rheumatologist to prescribe a course of Flagyl (10 days of treatment, 3 tablets a day) as a "therapeutic trial" for possible giardia infection. My son has been in remission since the Flagyl, for a little more than three years now (knock on wood!). In retrospect it is likely that my son had suffered from giardia-induced reactive arthritis with remission induced by Flagyl treatment. The child who could not walk before has joined both the varsity track and cross country teams at school, running 13 mile in practice last fall!.

Here are titles of articles from medline on giardia-induced (or parasite-induced) reactive arthritis: The first listed is the article we brought in to share with our rheumatologist:

1.http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9651093&dopt=AbstractLayton MA, Dziedzic K, Dawes PT. Sacroiliitis in an HLA B27-negative patient following giardiasis. Br J Rheumatol. 1998 May;37(5):581-3."…From a clinical viewpoint, we feel that this case highlights the necessity of taking a detailed history. In the specific case of giardiasis, the intestinal infection may be asymptomatic and the diagnosis may be overlooked in a patient presenting with ReA. This is important as antimicrobial chemotherapy appears to be curative… We conclude that chronic giardiasis needs to be excluded in patients presenting with a spondyloarthritis, abdominal symptoms and a suspicious travel history."(PDF file of the letter can be downloaded-click on link at the top of the abstract in Medline-the letter starts on page 5 of the PDF file)

2.http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9652890&dopt=AbstractLetts M, Davidson D, Lalonde F. Synovitis secondary to giardiasis in children. Am J Orthop. 1998 Jun;27(6):451-4. PMID: 9652890; UI: 98314998"Giardia lamblia, a gastrointestinal protozoan, is one of the most common disease-causing parasites in the world. Giardiasis is primarily encountered in areas with poor sanitation, but it is also seen in more developed countries. A possible sequela of Giardia infections of the bowel is reactive arthritis or synovitis. Arthropathy secondary to giardiasis is uncommon, but may be underdiagnosed."

just a small correction, the article we brought in to share with our rheumatologist can be downloaded as a PDF file, and it starts on the bottom of page 3, not page 5, of the file:http://rheumatology.oupjournals.org/cgi/reprint/37/5/581 Layton MA, Dziedzic K, Dawes PT.Sacroiliitis in an HLA B27-negative patient following giardiasis.Br J Rheumatol. 1998 May;37(5):581-3. No abstract available.PMID: 9651093

Hi Evelyn, I also have a son with AS diagnosed at 11, remission from 14-16 (puberty), now at 16 1/2 again having symptoms. I'm curious, is your son HLA pos.? We live in rural Hawaii, giardia is definitely around. Did your son have any giardia symptoms? Its wonderful to hear your story. Aloha, Nicole

My son is B27 negative, and the only one in the immediate family to have a spondyloarthropathy. He had strong diarrhea during our family trip on which we believe he contracted giardia, and had very vague and intermittent abdominal symptoms over the years, with occasional cramping and loose stools, but nothing consistent enough to have tipped us off to the idea of giardia. But as stated in the Layton letter, it is possible to have giardia-induced reactive arthritis with no abdominal symptoms at all. The case described in the Layton letter occurred in a B27 negative individual, however some of the cases of giardia-induced reactive arthritis described in the medical literature were in B27 positive individuals.

Dear Evelyn, thank you for answering so quickly. Our computer was not working for awhile hence this late response. Indeed, I found the references to HLAB27 pos people who had responded to giardia treatment. We often surf in breaks that have a lot of stream runoff, also have a stream adjacent to our land, I believe giardia is fairly common in Hawaii. Interesting that they mentioned in the article some childrens' symptoms strating with a swollen knee joint, this is also how my son's started, in fact he had laser surgery on his medial meniscus before the diagnosis of AS was made. I hope to get him tested/treated for giardia this week when his regular doctor is back, it certainly won't hurt, I'm trying not to get my hopes up too high. I haven't mentioned it to Dylan yet for the same reason. Thanks again for all your information and I'll keep you posted. aloha, Nicole

Dear Nicole, I wish you and your son best of luck. Please be aware that giardiasis can be quite hard to diagnose. That is one of the reasons that our rheumatologist chose to go ahead and treat with Flagyl without testing, as a therapeutic trial. Giardia cysts can be missed on examination of stool samples, even in an active infection, since cysts are shed only intermittently. If your doctor will want to test first, it probably should be done on repeated stool samples should a first test come back negative.

Please let me know if I can be of any further help in pursuing this possibility for your son.

Dear Evelyn, Dylan now has the Flagyl, the nurse practitioner who is his regular doctor places absolutely no faith in it and feels your story was all due to "coincidence". But I still feel its worth a try. We had some bad news this week, A back x-ray shows that Dylan is losing bone in his lumbar. Everyone is panicking. i'm very concerned about going to heavier drugs and yet this needs to be stopped. Also talked to the rheumatologist 2 weeks ago about alternatives, they are very set on their way of dealing with this and though they admit there are many possibilities out there they really don't have the knowledge to discuss them, or so it seems anyway. Did your son ever show any bone loss? I'm doing a lot of searching on alternatives, don't know if I should try them all or what. This is a very confusing and sad time. Dylan is doing O.K. He has had very little back problems, which is why the x-ray has everybody shocked. This particuloar flare is going on 4 months, the only other one he had lasted about 3 years, with a consistenly swollen knee. I'm not even sure these would be called flares.Anyway, I really appreciate the support of this web site. Aloha and happy holidays, Nicole (I am registered but cannot get my password to work)

I'm sorry to hear about Dylan's lumbar bone loss. My son only had a couple of short flares of sacroiliitis, and never did have back xrays. Bisphosphonates are drugs used for the prevention and even reversal of bone loss. Pamidronate, a member of the bisphosphonate group, has also recently been used to treat AS/spondyloarthropathies, so that might be a medication that could handle both the spondyloarthropathy and the bone loss. Jeanna (Strutsy) has just been started on this medication. Lou (Heronblu), a retired MD, has been receiving pamidronate infusions with great success. There is some information on pamidronate in the pharmacy forum. Additional information can be gotten by doing a search for "pamidronate" looking especially for posts by Strutsy and Heronblu.

I'm glad that you got the Flagyl. It is ABSOLUTELY worth a try!!! If it works, you all will be very happy, and if it doesn't work, then it will be back to the drawing board with nothing lost.

I'm sorry to read about the scepticism of the nurse practitoner re:flagyl/giardia-induced reactive arthritis. It is unfortunate that more practioners are not familiar with this condition, since it is so treatable. I will tell you that the first time I mentioned the idea that a parasite such as giardia might be involved to our pediatric rheumatologist he was also sceptical. I then was able to provide him the reprint of the Layton letter from the British Journal of Rheumatology (for access to this article, see below), and having this medical reference convinced him of giardiasis as a bona fide cause of spondyloarthropathy. I would suggest that you send your nurse practioner a copy of one or more of the medical references listed in the first post, or at least send her the reference list. She should become informed of the medical literature that supports the diagnosis of giardia-induced spondyloarthropathy, and this information may even help her to help others in the future as well.

Here's access to the article we brought in to share with our rheumatologist. It can be downloaded as a PDF file, and it starts on the bottom of page 3 of the file:

Hi Evelyn, Here is the latest on Dylan. He did the flagyl and there was no noticeable effect, however i still feel the infection angle is worth pursuing. He is now under the care of a naturopath as well as a rheumy. The naturopath recommende a thorough stool sample to find out what might be going on with parasites, infection, as well as several other things. This is not the one typically done here but one that is sent off to S. Carolina. We should have some results in a bout a week and a half. His rheumy has put him on azulfadineEN (which apparently is Ebringer's drug of choice) because she is not seeing any effect from the indocin. In fact he has bone erosion where his achilles attaches that wasn't there before the indocin. We are also trying for the LSD (a challenge as you can imagine) and he's taking fish oils, bromelain, boswella, and acidophilus (recommendations from the Zampieron book). The stool sample will give us more info I hope. Thanks for keeping in touch, it is nice to talk with another mom who has been through this and you have so much good information. Aloha, Nicole